Prostate Cancer, Advanced or Metastatic

Topic Overview

Is this topic for you?

This topic is about
prostate cancer that has spread or come back after treatment. For information on prostate cancer that has not spread outside the prostate (localized prostate cancer), see the topic Prostate Cancer.

What is prostate cancer?

Prostate cancer is a group of cells that grows faster than normal in a
man's prostate gland. It can spread into other areas and kill normal
tissue.

The
prostate gland sits just below a man's bladder. It makes part of the fluid for
semen. In young men, the prostate is about the size of
a walnut. It usually grows larger as you grow older.

Recurrent prostate cancer. This is cancer that has
come back after it was treated. The cancer can come back in the prostate, near
the prostate, or in another part of the body. If it comes back in another part
of the body—often the bones—it is still called prostate cancer, because it
started in the prostate.

What causes prostate cancer?

Experts don't know what causes prostate cancer. But they believe that
getting older and having a family history of prostate cancer raise your chance
of getting it.

What are the symptoms?

Sometimes there are no symptoms of either locally
advanced or metastatic prostate cancer.

When they do appear,
symptoms of locally advanced prostate cancer include:

Waking up many times during the night to urinate.

Having trouble starting your urine stream, having a
weaker-than-normal stream, or not being able to urinate at all.

Having pain or a burning feeling when you urinate.

Having blood in your urine.

Having a deep pain or stiffness in your lower back, upper
thighs, or hips.

Symptoms of metastatic prostate cancer may include:

Bone pain.

Weight loss.

Swelling in your legs and feet.

How is prostate cancer diagnosed?

A blood test called a prostate-specific antigen (PSA) test is the most common way to check for prostate cancer. A higher level of PSA may mean that you have prostate cancer or that your prostate cancer has come
back.

Your doctor also may do a
biopsy. In this test, your doctor takes samples of
tissue from your prostate gland or from the area where the cancer may have
spread and sends the samples to a lab for testing. A biopsy is the only way to
know for sure that you have prostate cancer.

If you have had
prostate cancer before, your doctor may also order a
bone scan,
CT scan, or
MRI to see if it has come back or spread.

Learning that you have cancer that has spread or come back can be very hard. Some people find that it helps to talk about their feelings with their family and friends. You may also want to talk with your doctor or with other people who have had this kind of cancer. Your local American Cancer Society chapter can help you find a support group.

How is it treated?

Your treatment choices depend on your overall health,
how fast the cancer is growing, and how far it has spread.

Locally advanced prostate cancer may be treated with surgery, radiation
therapy, hormone therapy, or a combination of these.

Treatment of metastatic cancer
focuses on slowing the spread of the cancer and relieving symptoms, such as
bone pain. It also can help you feel better and live longer. Treatment may
include hormone therapy, radiation therapy, chemotherapy, or immunotherapy.

In some cases, men may be able to wait before starting treatment (active surveillance). But older men with other serious health problems may decide not to have treatment except for what is needed to treat any symptoms (watchful waiting).

Cause

The exact cause of
prostate cancer is not known, but experts believe your
age and family history may have something to do with your chances of getting
the disease. Prostate cancer is very common and is an older man's disease. Most
men who get it are older than 65.

Benign prostatic hyperplasia (BPH), which is an
enlarged prostate. This is very common in older men. The prostate usually grows
larger with age. When it gets large enough, it can press against the urethra
and cause urination problems.

Symptoms that may mean the cancer has spread to other
parts of the body, or metastasized, include:

Weight loss.

Bone pain.

Swelling in the legs and feet.

What Happens

Prostate cancer is a common cancer affecting older
men. About 16 out of 100 men in the United States will get prostate cancer, but only 3 will die because of it. That means about 97 out of 100 men will die of something other than prostate cancer.1

It usually is a very
slow-growing cancer that takes years to grow large enough to cause any
symptoms. In some men, it never does cause problems. Sometimes, though, it
grows quickly and may cause complications or death.

When prostate
cancer grows large enough, it begins to fill the prostate and often can be felt
by your doctor during a
digital rectal exam. As it continues to grow, it
breaks through the outer rim of the prostate and into nearby tissues, such as
the
seminal vesicles. At this point, the disease is called
locally advanced prostate cancer.

Locally advanced prostate cancer is usually not curable. But there are treatments that can help you live longer and feel better. Most men live up to 5 years after this diagnosis, but some men may
live longer.2

After the
cancer has broken through the prostate, it may move into nearby lymph nodes.
From the lymph node system, the cancer can spread to other areas of the body.
Most often, prostate cancer spreads to the bones. It also may spread to the
lungs or other organs. When it has spread to the
lymph nodes, the disease is called metastatic prostate cancer.

Metastatic prostate cancer is not curable. But a
number of treatments are available to help you live longer and make you feel
better. Most men live 1 to 3 years after this diagnosis, but some men may
live many years longer.2

What Increases Your Risk

A risk is anything that makes
you more likely to get a particular disease. Being older than 50 is the main
risk for
prostate cancer. About 6 out of 10 new prostate
cancers are diagnosed in men who are 65 and older.3

Your chances of getting the disease are higher
if other men in your family have had it. Your risk is doubled if your father or
brother developed prostate cancer. Your risk also depends on the age at which your relative was diagnosed. Most
men who get prostate cancer have no family history of the disease.

Race and prostate cancer

African-American
men and Jamaican men of African descent have a greater chance of developing the
kind of prostate cancer that grows and spreads. Researchers are not sure why
there is a difference in disease and death rates among different races. Some
experts think there may be a genetic link.4

When To Call a Doctor

Call your doctor immediately if you:

Are completely unable to urinate.

Have painful urination and a fever higher than
100°F (37.78°C), chills, or
body aches.

Have blood or pus in your urine or semen.

Call your doctor to schedule an appointment if you have
unexplained:

Weight loss.

Dull, aching pain in your lower back, pelvis, or hips.

Swollen
lymph nodes in the groin area. These nodes are usually
not tender.

Active surveillance or watchful waiting

Active surveillance means a man will be watched closely by his doctor and have regular checkups and tests, including prostate biopsies. If the cancer starts to grow more quickly, he will have other treatment.

Active surveillance is an option for men with low-risk cancer who expect to live more than 10 years and don't have other chronic health problems. It may be an option for some men with intermediate-risk prostate cancer. But active surveillance usually is not a choice when prostate cancer has spread.

Sometimes men who have PSA levels that are rising slowly after having treatment may not start hormone treatments right away but be monitored with active surveillance.

Watchful waiting means a man will be watched closely by his doctor but not have treatments that try to get rid of the cancer. If an older man has serious health problems and isn't expected to live more than 10 years, he may not be able to handle treatments or even want to have treatments except those needed to keep him comfortable (palliative care).

Exams and Tests

A
digital rectal exam, in which the doctor inserts a
gloved finger into your rectum to feel your prostate gland. Some prostate
tumors can be found this way.

A
PSA test to measure the levels of prostate-specific
antigen (PSA) in your blood. A higher level of PSA may indicate an enlargement,
infection, or cancer of the prostate. A rising PSA level after treatment for
prostate cancer can mean your cancer has come back.

A transrectal ultrasound, in which the doctor inserts a probe into your rectum to check your prostate. The probe uses sound waves (ultrasound) to create a picture of the prostate.

A
prostate biopsy, in which tissue is taken from your
prostate and examined under a microscope. The other exams and tests
can give clues that you may have prostate cancer, but only a prostate biopsy can
tell for sure.

If you have had prostate cancer before, one or more tests
will help your doctor see if your cancer has come back or spread. These may
include:

Blood tests. Different types of blood tests are used to see
whether cancer has spread to your bones or liver.

A
bone scan. Radioactive material that shows up on
X-rays is injected into your arm. An X-ray camera passes over your body, taking
pictures as the radioactive material moves into your bones. Areas of bone
damage show up in the pictures. Prostate cancer that has spread to the bones
can cause this kind of damage.

A
CT scan. A CT scanner directs a series of X-ray pulses
through your body. Each X-ray pulse lasts only a fraction of a second and
represents a "slice" of the organ or area being studied.

An
MRI. An MRI uses a strong magnetic field to make
pictures of the prostate. This can show tissue damage or disease, such as
infection or a tumor.

Follow-up checkups

If
you have been treated for prostate cancer in the past, you've probably been
having regular checkups that include
PSA tests to check for any signs that the cancer has
come back or has spread to other parts of your body. Your doctor will watch for
any increases in your PSA level and the speed with which any increases occur. A
higher PSA does not necessarily mean your cancer has come back. But it may mean that you need further tests, such as a prostate biopsy, bone scan, CT scan, or
MRI.

Treatment Overview

Your treatment options for prostate cancer that has spread will depend on:

What kind of cancer cells you have. This is called the
grade or Gleason score of your cancer. Some prostate
cancer cells grow more quickly than others.

Treatment for
locally advanced or
metastatic prostate cancer may include hormone
therapy, surgery, radiation therapy, chemotherapy, or immunotherapy. Or if you aren't having symptoms, it may include active surveillance or watchful waiting.

You may
want to talk with your doctor about entering a
clinical trial of new cancer treatment options. A treatment being studied in clinical trials for advanced prostate cancer is high-intensity-focused ultrasound (HIFU). For metastatic prostate cancer, treatments in clinical trials include new forms of chemotherapy and immunotherapy, including vaccines.

Treatment for locally advanced prostate cancer

Prostate cancer that has spread to
tissue around the prostate may be treated with radiation therapy, surgery, or hormone therapy. Sometimes two of these treatments are combined.

Radiation therapy

Radiation therapy uses high-energy
X-rays or protons to destroy the cancer. This treatment has improved with newer technologies, so there
are fewer side effects and complications than in the past. Radiation therapy
usually is combined with hormone therapy.

External beam radiotherapy, or EBRT, uses high-energy rays,
such as X-rays, to destroy the cancer. It is usually given in multiple doses
over several weeks. Radiation destroys tissue, so it may damage the
nerves along the side of the prostate that affect your ability to have an
erection. If you already have bowel problems, external radiation may cause your
symptoms to get worse.

Three common forms of external radiation are:

Conformal radiotherapy (3D-CRT).
This uses a three-dimensional planning system to target a strong dose of radiation
to the prostate cancer. This helps to protect healthy tissue from
radiation.

Proton beam therapy. This is radiation therapy that uses a different type of energy (protons) rather than X-rays. This allows a higher amount of specifically directed radiation, which protects nearby healthy tissues (especially the rectum). Sometimes proton beam therapy is combined with X-ray therapy. (It is available only at big medical centers.)

Surgery

Transurethral resection of the prostate (TURP). This surgery can help relieve bladder problems, because it
removes part of the tumor that may be blocking the
urethra, the tube that carries urine from your bladder
through your penis. The procedure is done under
general anesthesia. This can keep the tumor from
growing for a while. But TURP does not take out the whole tumor.

Hormone therapy

Hormone therapy is also called androgen deprivation therapy (ADT). Prostate cancer needs male
hormones (testosterone) in order to survive. Hormone therapy
decreases the amount of testosterone and other male hormones in your body. This
often causes tumors to shrink. Shrinking the tumors can ease severe bone pain
caused by the spread of cancer to the bones. Hormone therapy usually is
combined with radiation therapy.

The most common methods are:

LH-RH agonists and GnRH agonists. These drugs, such as
goserelin (Zoladex), leuprolide (Lupron), and triptorelin (Trelstar),
stop the body from making testosterone.

GnRH antagonists. These drugs stop the body from making testosterone. They work right away and avoid the flare caused by GnRH agonists that can make symptoms worse for several weeks. One GnRH antagonist is degarelix (Firmagon).

Antiandrogens. These drugs, such as bicalutamide
(Casodex), often are used along with LH-RH agonists. Antiandrogens help block
the body's supply of testosterone.

Orchiectomy. This is surgery to remove
the testicles, which produce more than 90% of the body's male hormones (androgens), including testosterone.

Combination treatments

In some cases, men will have radiation therapy after a
prostatectomy, especially if the tumor could not be completely removed by
surgery.

Some men choose to start hormone therapy only after they
have symptoms. But many doctors recommend starting hormone therapy right away
if cancer is found in the
lymph nodes during surgery to remove the prostate. Early treatment may allow
men to live a little longer. Other doctors say to wait, because waiting delays
the bothersome and serious side effects of hormone therapy.

Treatment for metastatic prostate cancer

Treatment for
prostate cancer that has spread to the bones and/or
other organs in the body is aimed at relieving symptoms and slowing the
cancer's growth. Treatment may include:

Hormone therapy works by decreasing the amount of testosterone in your body. This can be done with medicine or with surgery to remove the testicles (orchiectomy). Hormone therapy can also relieve pain by shrinking tumors and easing urinary
problems.

Sometimes
androgen deprivation (orchiectomy or an LH-RH agonist) and an antiandrogen are
used together. This is called a combined androgen blockade (CAB). But the slight benefit of CAB may be offset by side effects.

Both orchiectomy and hormone therapy medicine make
testosterone levels drop, causing some of the same side effects. These include
larger breasts,
hot flashes, loss of sexual desire, and the inability
to have an erection. Treatment options for these problems include:

Taking a temporary break from hormone therapy. This can make
some side effects go away. (Side effects after orchiectomy are
permanent.)

Radiation treatment of the breasts to prevent breast growth.
This is done before starting hormone therapy.

Radiation treatment or the anti-estrogen breast cancer medicine
called tamoxifen to relieve breast pain. Tamoxifen can also help reverse breast
growth. It also causes hot flashes.

Taking medicines to control hot flashes, such as paroxetine or
venlafaxine. If these don't work, sometimes estrogen or
megestrol may help reduce hot flashes. But all of these medicines have
different side effects, so if you are having a problem with hot flashes, talk
with your doctor.

Some men choose
to start hormone therapy only after they have symptoms. But some doctors
recommend starting hormone therapy right away if cancer is found in the
lymph nodes during surgery to remove the prostate. Other doctors say to wait, because waiting delays
the bothersome and serious side effects of hormone therapy.

With intermittent androgen deprivation, known as IAD,
men take cycles of hormone therapy medicines. Taking breaks between
hormone therapy cycles gives men the chance to recover their ability to
function sexually. It also gives relief from the other side effects of hormone
therapy, including hot
flashes, the loss of energy, and the loss of bone and muscle mass.

Hormone therapy usually works well at first to stop
cancer growth. But in most cases, the cancer begins to grow again within a few years. At this
point, the cancer is described as hormone-resistant,
meaning it is not responding to standard hormone therapy. When this happens,
other kinds of hormone treatments may be tried.

When hormone treatments no longer keep the cancer from growing, the cancer is called castrate-resistant prostate cancer (CRPC). Treatments that may be used to help men live longer include chemotherapy, immunotherapy, and medicines like enzalutamide.

Treatment for pain

Pain is one of the main concerns of people who have metastatic cancer. But cancer pain can almost always be controlled. You and your doctor have several options to help your pain, including pain-relieving medicines and radiation, such as external beam radiation therapy and bone-targeted radioisotopes.

Additional information about prostate cancer is provided by the National Cancer Institute at www.cancer.gov/cancertopics/types/prostate.

Palliative care

Palliative care is a kind of care for people who have a serious illness. It's different from care to cure your illness. Its goal is to improve your quality of life—not just in your body but also in your mind and spirit.
You can have this care along with treatment to cure your illness.

Palliative care providers will work to help control pain or side effects. They may help you decide what treatment you want or don't want. And they can help your loved ones understand how to support you.

Hospice care

For some people who have advanced cancer, a time comes when treatment to cure the cancer no longer seems like a good choice. This can be because the side effects, time, and costs of treatment are greater than the promise of cure or relief. But you can still get treatment to make you as comfortable as possible during the time you have left. You and your doctor can decide when you may be ready for hospice care.

Diarrhea. Don't eat until you are feeling better. Take
frequent, small sips of water or a rehydration drink and small bites of salty
crackers. Begin eating mild foods (such as rice, dry toast or crackers,
bananas, broth, and applesauce) the next day or sooner, depending on how you
feel.

Constipation. Make sure you drink enough fluids. Most
adults should drink between 8 and 10 glasses of water or noncaffeinated
beverages each day. Include fruits, vegetables, and fiber in your diet each
day.

Sleep problems. Often, simple measures such as having
a regular bedtime, getting some exercise during the day, and avoiding caffeine
late in the day can relieve sleep problems.

Urinary problems. Home treatment for urinary
incontinence includes eliminating caffeinated drinks from your diet and
establishing a schedule of urinating every 3 to 4 hours, regardless of whether
you feel the need. You may also try doing
pelvic floor (Kegel) exercises to strengthen your
pelvic muscles.

During medical treatment for prostate cancer, you may
experience emotional problems. See the following tips for managing:

Stress. Expressing your feelings to others may help
you understand and cope with them. Learning relaxation techniques may also be
helpful.

Body image and sexuality. Your feelings about your body and your sexuality may
change after treatment for cancer. Prostate cancer treatments have side effects that almost always affect a man's sexual function, such as loss of sexual desire and the inability to have erections. Treatments can also cause shrinking of the penis and testicles. Talk openly with your partner about your concerns. And discuss with your doctor your concerns about any sexual problems.

Medications

Medicines may be used to slow the growth of
prostate cancer and to relieve your symptoms.

Prostate cancer needs the male hormone
testosterone to grow. Hormone therapy uses special
drugs to block the production or action of testosterone and may cause the
cancer to shrink. This can improve your symptoms. Hormone therapy may be given
before or after
radiation or
surgery to remove the prostate.

Hormone therapy usually works well at
first to stop cancer growth. But in most cases the cancer returns in a few
years. At this point, the cancer is called hormone-resistant. This means it will no longer get better
with hormone therapy. When this happens, other kinds of hormone treatment may
work. If the cancer continues to grow, chemotherapy or immunotherapy may be the next choice.

Chemotherapy is the use of drugs to control cancer's
growth or relieve pain. Often the drugs are given through a needle in your
vein, and your blood vessels carry the drugs through your body. Sometimes the
drugs are available as pills you can swallow. Sometimes they are given through
a shot, or injection.

Chemotherapy usually involves two or more
drugs given together. Combinations may work better than a single medicine. That's because each drug can attack the cancer cells in a different way. This is most often used when prostate cancer
is hormone-resistant.

Immunotherapy is treatment that uses the body's
immune system to destroy the cancer cells. This is used for prostate cancer that is hormone-resistant.

Medicine Choices

Hormone therapy

LH-RH agonists/GnRH agonists, such as goserelin (Zoladex) and leuprolide
(Lupron).

Medicines for castrate-resistant prostate cancer (CRPC)

Immunotherapy with sipuleucel-T (Provenge), a vaccine given by injection.

Pain-relief and appetite-stimulant drugs

Pain-relief and appetite-stimulant drugs may be used when prostate cancer
has spread to other parts of the body.

Steroids, such as hydrocortisone or prednisone,
control pain and improve appetite.

Radioactive drugs, such as radium-223 (Xofigo), samarium-153, and strontium-89, are
called radionuclides. They are absorbed near the area of bone pain. Then the
radiation that is released helps relieve the pain caused by tumors that have
spread to the bone.

Denosumab (Xgeva) and bisphosphonate drugs, such as pamidronate (Aredia) and zoledronic acid (Zometa), may help relieve
bone pain and prevent
osteoporosis, which is sometimes caused by long-term
hormone therapy.

Pain medicines are made that specifically treat mild,
moderate, and severe pain, as well as different types of pain such as burning
and tingling. To learn more, see:

Medicines for treating side effects

For men who have erection problems after surgery, medicines
such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra) may be
helpful. Using medicines soon after surgery may help men regain sexual function. Talk with your doctor about your situation.

Taking a temporary break from hormone therapy can make some
side effects go away.

To relieve breast pain, the anti-estrogen breast cancer
medicine called
tamoxifen or radiation treatment is commonly used.
Tamoxifen can also help reverse breast growth. Also, it causes hot
flashes.

For hot flashes, taking a certain kind of
antidepressant may help.
Paroxetine or venlafaxine may help with hot flashes. But they have different side effects. So if you are having a problem with hot flashes, talk
with your doctor.

What to think about

Antiandrogen hormone therapy also
may cause diarrhea, breast tenderness, and nausea. Cases of liver problems,
some serious, have been reported.

Hormone therapy can also affect the bones, making them thin and brittle and more likely to break. Medicines such as bisphosphonates and denosumab may help prevent bone loss during long-term hormone therapy.

Surgery

Surgery to treat
prostate cancer is usually reserved for men in good
health who are younger than 70 and who choose to have surgery. Surgery may be
done to relieve symptoms and to slow the growth of cancer.

Surgery choices

Radical prostatectomy, the removal of the prostate and
its cancer. It is not usually done if the cancer has spread to other parts of
the body.

Orchiectomy, the removal of the testicles. This may
cause the cancer to shrink and may improve symptoms, because prostate cancer
often needs the testosterone made by the testicles to grow.

TURP, or transurethral resection of the prostate. This
operation can help to relieve bladder problems, because it removes part of the
tumor that may be blocking the urethra, the tube that carries urine from your
bladder through your penis. This can keep the tumor from growing for a while.
But TURP does not take out the whole tumor.

What to think about

Surgical
removal of the testicles (orchiectomy) and hormone therapy medicines have some
of the same side effects, including hot flashes, larger breasts, loss of sexual
desire, and the inability to have an erection.

Other Treatment

Radiation therapy

Radiation therapy for
prostate cancer may be used alone or combined with
hormone treatment. Radiation therapy also is used to relieve
pain from metastatic cancer or cancer that comes back after surgery.

Radiation therapy for locally advanced prostate cancer is often combined
with hormone treatment. Using both together may improve your chances of being
disease-free for longer and living longer.2

External-beam radiation therapy uses a large machine
to aim a beam of radiation at your tumor to destroy cancer cells. The radiation
damages the genetic material of the cells so that they can't grow. Although
radiation damages normal cells as well as cancer cells, the normal cells can
repair themselves and function, while the cancer cells cannot. If cancer has
spread to your bones, radiation treatment may be given to specific areas to
relieve pain.

Complementary therapy

People sometimes use complementary therapies along with medical treatment to help relieve symptoms and side effects of cancer treatments. Some of the complementary therapies that may be helpful include:

Acupuncture to relieve pain. Acupuncture may also help reduce hot flashes from taking hormone therapy.

Mind-body treatments like those mentioned above may help you feel better and cope better with treatment. These treatments also may reduce chronic low back pain, joint pain, headaches, and pain from cancer treatments.

Before you try a complementary therapy, talk to your doctor about
the possible value and potential side effects. Let your doctor know if you are
already using any such therapies. Complementary therapies are not meant to take
the place of standard medical treatment, but they may improve your quality of
life and help you deal with the stress and side effects of cancer treatment.

Clinical trials

You
may be interested in taking part in research studies called clinical trials. Clinical trials are designed to
find better ways to treat prostate cancer patients and are based on the most up-to-date information. People who do not want standard treatments or are not cured by standard treatments may want to take part in
clinical trials.

Check with your doctor to see whether clinical trials are in your area and whether you might be eligible.

Other Places To Get Help

Organizations

American Cancer Society (ACS)

Web Address:

www.cancer.org

National Cancer Institute (U.S.)

Web Address:

www.cancer.gov (or https://livehelp.cancer.gov/app/chat/chat_launch for live help online)

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